Friday, March 16, 2018

Adolescents With Mental Health Conditions More Likely to Transition to Long-Term Opioid Therapy, Study Finds

Adolescents with preexisting mental health conditions may be more likely than their peers to transition from a first opioid prescription to long-term opioid therapy, according to a study published this week in JAMA Pediatrics.

“Given the limited support for the efficacy of opioid therapy for chronic pain among youths, research is needed to understand potential adverse effects of LTOT [long-term opioid therapy] among adolescents as well as the role that preexisting mental health conditions may play in harmful outcomes,” lead author Patrick D. Quinn, Ph.D., of Indiana University and colleagues wrote.

For the study, Quinn and colleagues analyzed data from the 2003-2014 Truven Health MarketScan Commercial Claims and Encounters (MarketScan) databases of commercial health care insurance claims. The researchers identified a cohort of more than 1.2 million adolescents aged 14 to 18 who received opioids for the first time during this period. The researchers then tracked this group from their first prescription until their first disenrollment or December 31, 2014 (whichever occurred first), to examine subsequent long-term opioid therapy (defined as more than 90 days’ supply within a six-month window having no gaps in supply of more than 32 days).

Associations between preexisting mental health conditions and treatments and any opioid receipt were examined by comparing adolescents who received any opioid analgesic with those who did not matched on sex, calendar year and years of age of first enrollment, and months of enrollment.

The authors found that 3.0 per 1,000 opioid recipients transitioned to long-term opioid therapy within three years of fulfilling an initial opioid prescription. “Although adolescents with a wide range of preexisting mental health conditions and treatments were modestly more likely than adolescents without those conditions or treatments to receive an initial opioid, the former had substantially higher rates of subsequent transitioning to LTOT [long-term opioid therapy],” the authors wrote. 

“There is a clear need for mental health assessment among adolescents being considered for opioid therapy. Such an assessment may help inform decision making regarding pain treatment as well as illuminate the possible value of concomitant mental health interventions,” they concluded.

In an accompanying editorial, Michael J. Mason, Ph.D., of the University of Tennessee, Knoxville, wrote, “These findings are important clinically and provide a foundation for future research to test the efficacy and potential adverse effects of long-term opioid therapy for adolescents with and without comorbid diagnoses. This research has highlighted the need to address comorbidity by addressing the accompanying risk and protective factors—a challenging task but one that would provide immediate translational guidance for pediatric practitioners.” 

For related information, see the Psychiatric News article “Many Prescription Opioids Go to Adults With Depression, Anxiety.”
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Thursday, March 15, 2018

Nondisclosure of Suicidal Intent Following Gunshot Wound Presents Barrier to Care, Study Finds

Some survivors of self-inflicted gunshot wounds falsely deny their injuries are a result of a suicide attempt. According to a study published today in Psychiatric Services in Advance, these patients are far less likely to receive inpatient psychiatric care following their injury than those who disclose suicidal intent.

The results highlight the importance of increased assessment, intervention, and psychoeducation for survivors of self-inflicted gunshot wounds, particularly while they are hospitalized on medical floors, wrote Michael Matthew McClay, M.S., of Western Kentucky University, Stephen S. O'Connor, Ph.D., of the University of Louisville, and colleagues. Because survivors of suicide attempts are at high risk of recurrence, correctly identifying these individuals is critical so treatment and prevention efforts can ensue, wrote the authors.

About 44,000 people die by suicide every year in the United States, making it the 10th most common cause of death. Suicide attempts occur at an even greater rate and result in more than 316,000 hospital admissions and $51 billion in combined costs of medical care and loss of work each year, the authors wrote.

The researchers examined electronic medical record data from 128 survivors of self-inflicted gunshot wounds at a trauma center in Tennessee; more than 25% of these patients were known to have made a prior suicide attempt.

Overall, 71% of the survivors of self-inflicted gunshot wounds disclosed that it was a suicide attempt, and 29% denied it. Of patients who denied the suicide attempt, about 40% (16 patients) were flagged during a psychiatric consultation as presenting under circumstances suspicious of a suicide attempt. Suicide attempt was suspected in some cases due to reports from witnesses or conflicting stories by the patients regarding the circumstances of their injury, for instance.

Patients who denied their suicide attempt were more than 10 times more likely to be discharged to home than to inpatient care, compared with patients who disclosed an attempt, the study found.

“Within acute care center settings, the desire to avoid inpatient psychiatric hospitalization and documentation in the medical record may be barriers to reporting that a self-inflicted gunshot wound was intentional,” the researchers wrote. “[T]he results indicate a need for further reflection on ways in which usual care in health systems (such as inpatient hospitalization) may present a barrier for eliciting honest reports from suicide attempt survivors due to a fear of hospitalization.”

For related information, see the book Gun Violence and Mental Illness, co-edited by Liza Gold, M.D., and Robert I. Simon, M.D.

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Wednesday, March 14, 2018

Adults Who Play Violent Video Games Appear No More Aggressive Than Those Who Don’t

Frequently playing violent video games does not appear to promote aggression, reduce empathy, or alter mood and cognition in healthy adults, according to a study published Tuesday in Molecular Psychiatry.

These “results provide strong evidence against the frequently debated negative effects of playing violent video games,” wrote Simone Kühn, Ph.D., of the Max Planck Institute for Human Development in Berlin, Germany, and colleagues. The authors noted that this debate has been largely fueled by studies showing short-term effects when tests were administered immediately after game playing.

“[I]n our view, the question that society is actually interested in is not: ‘Are people more aggressive after having played violent video games for a few minutes? And are these people more aggressive minutes after gameplay ended?’ but rather ‘What are the effects of frequent, habitual violent video game playing? And for how long do these effects persist (not in the range of minutes but rather weeks and months)?’” Kühn and colleagues wrote.

To investigate the long-term behavioral effects of playing violent video games, Kühn and colleagues randomly assigned 90 healthy adults who reported little or no video game use in the past six months to one of three groups: violent video games, nonviolent video games, or no video games. Participants assigned to the violent and nonviolent game groups were instructed to play Grand Theft Auto V and Sims 3, respectively, on a PlayStation 3.

Before the video game training period, all participants completed questionnaires and computerized tests assessing aggression, impulsivity, empathy, symptoms of depression and anxiety, and executive control. These tests were repeated after the video game training period and again two months later.

“No significant changes were observed, neither when comparing the group playing a violent video game to a group playing a nonviolent game, nor to a passive control group. Also, no effects were observed between baseline and posttest directly after the intervention, nor between baseline and a follow-up assessment two months after the intervention period had ended,” Kühn and colleagues wrote.

While the authors noted that these findings stand in contrast with the results of some short-term studies of violent video games, they wrote that more research is needed to determine whether playing violent video games during childhood leads to similar or different long-term behavioral effects.

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Tuesday, March 13, 2018

Severe Asthma in Adolescents May Increase Risk of Bipolar Disorder, Schizophrenia

Adolescents whose asthma required hospitalization may be at a greater risk of developing bipolar disorder or schizophrenia, according to a report in Schizophrenia Bulletin. The cohort study of more than 2 million Swedish children and their parents also revealed an association between asthma in the mothers and/or fathers and bipolar disorder in the children.

“As far as we are aware, this is the first study to find increased risk of bipolar disorder in children of individuals with asthma,” wrote Joseph Hayes, M.D., of University College London and colleagues. “Asthma admissions before aged 11 do not appear to be linked to bipolar or schizophrenia spectrum disorders.”

Hayes and colleagues collected data from Swedish registers from 1973 through 2011. These registers contain sociodemographic and medical information on each resident of Sweden, and parents can be linked to children via a unique identifier. The researchers included all children born in Sweden from 1973 to 1995 and their parents in the study cohort.

Children were grouped according to the age of first inpatient admission for asthma: at 5 years of age or younger, 6 to 10 years of age, and 11 to 15 years of age. Hospital admissions of the mothers and fathers for asthma prior to the birth of the children were also recorded.

Of the more than 2 million individuals born in Sweden between 1973 and 1995, 40,187 (1.78%) children were admitted with asthma before the age of 15, and 9,892 (0.44%) children were born to mothers who were hospitalized for asthma before their birth.

Following adjustment for confounding factors, the researchers found that there was an association between asthma admission between age 11 and 15 and both bipolar disorder (hazard ratio [HR] = 1.73) and schizophrenia spectrum disorder (HR = 1.62). There was no association between asthma and bipolar disorder and schizophrenia in children who were admitted for asthma before age 11. Additional analysis also revealed an association between both maternal and paternal asthma and bipolar disorder, but not between parental asthma and schizophrenia spectrum disorders.

“Taken together, our results do not suggest a straightforward link between asthma and severe mental illness via neurodevelopmental effects of inflammation, but potentially there is shared genetic vulnerability,” the authors wrote. “This finding has implications for understanding the differential pathogenic mechanisms of bipolar and schizophrenia spectrum disorders.”

For related information, see the Psychiatric News article “When Should Psychiatrists Manage [Other] Medical Conditions.”

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Monday, March 12, 2018

Light Therapy for Bipolar Depression Poses Minimal Risk of Mania Switching

Light therapy has been shown to be an effective treatment for bipolar depression, but there have been concerns that light therapy might increase the risk of triggering mania or hypomania in patients with bipolar disorder.

A meta-analysis published in the March issue of Psychiatry Research suggests that the risks of switching into mania during light therapy are quite low—roughly the same risk of switching among patients with bipolar disorder taking placebo medications in clinical studies.

Francesco Benedetti, M.D., of the Scientific Institute Ospedale San Raffaele in Milano, Italy, analyzed data from 41 studies evaluating the effects of light therapy on patients with bipolar depression. Of the 799 patients included in these studies, only 7 (0.9%) switched into mania and 11 (1.4%) switched into hypomania. Three of the patients who switched into mania had rapid-cycling bipolar disorder, which the authors noted is a risk factor for switching.

Further analysis of the data showed that the risk of switching was independent of the treatment design (for example, light intensity or time of day of treatment). However, the rate of switching varied based on how the investigators screened for mania symptoms. Among studies that used a mental state examination to assess mania, the identified switching incidence was 0.8%, while in studies that used clinical rating scales, the incidence was 3%.

Benedetti noted that the 3% risk of a patient switching into mania following light therapy is still a lower risk than most other treatment options. Current estimates suggest mania emerges in about 4% of bipolar patients taking a placebo medication, 6% to 8% of unipolar depression patients taking antidepressants, and 15% to 40% of bipolar depression patients taking antidepressants.

Benedetti cautioned that since the 41 studies included in the meta-analysis were quite different in their protocols, more well-designed trials are required to investigate the optimal intensity and frequency of light therapy for bipolar depression. “Overall, these observations do not justify specific safety concerns for the risk of manic switches when using this treatment option in patients with bipolar depression,” he concluded.

To read more about this topic, see the Psychiatric News article “Adjunctive Light Therapy Found Effective for Bipolar Depression.”

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Friday, March 9, 2018

ECT Does Not Appear to Increase Risk of Dementia

Electroconvulsive therapy (ECT) does not appear to increase long-term dementia risk in patients, according to a study published online this week in Lancet Psychiatry.

“The findings from this study support the continued use of ECT in patients with severe episodes of mood disorders, including those who are elderly,” wrote Merete Osler, D.Msc., of the Center for Clinical Research and Prevention at the Bispebjerg and Frederiksberg Hospitals in Denmark and colleagues.

ECT is considered a highly effective treatment for severe episodes of mood disorder, particularly major depression, the authors noted. Temporary memory loss is a common side effect, especially with bilateral lead placement and increasing number of treatments. Although such memory loss tends to resolve within weeks, few studies have examined whether patients who receive ECT have a greater risk of long-term adverse cognitive outcomes.

For the study, researchers identified about 168,000 patients aged 10 or older in the Danish National Patient Registry who were hospitalized with a first-time diagnosis of affective disorder from 2005 through 2015. Of these patients, nearly 6,000 (3.5%) underwent at least one ECT during the median 5-year follow-up, with the percentage highest among middle-aged patients. ECT was most common in those with severe depression, comorbid schizophrenia, or in those who used antidepressants or antipsychotic medication.

Of patients who underwent ECT, 3.6% developed dementia. Of some 162,000 patients not treated with ECT, 3.1% developed dementia. Researchers found that after adjusting for the potential effect of patient selection or competing mortality, ECT was not associated with risk of dementia.

In patients younger than 69 years old, ECT was not associated with an increased risk of dementia, compared with age-matched patients who were not given ECT. In patients aged 70 years and older, ECT was associated with a decreased rate of dementia. Furthermore, the risk of developing dementia was lower for patients aged 70 and older who had more than ten sessions of ECT.

“The potential adverse effects of ECT on cognitive function might have fueled the fear of dementia in patients and clinicians, and for that reason they might hesitate to choose ECT as a treatment,” the authors wrote. “The findings from this study show that notwithstanding other possible adverse long-term cognitive effects, ECT did not increase the risk of dementia, and support the continued use of ECT in patients with severe episodes of mood disorders, including those who are elderly.”

For related information, see the Psychiatric News article “High-Dose, Unilateral ECT Found as Effective as Bilateral ECT.”

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Thursday, March 8, 2018

FDA Approves Latuda for Treatment of Youth With Bipolar Depression

The Food and Drug Administration (FDA) has approved Latuda (lurasidone HCl) for the treatment of depressive episode associated with bipolar I disorder (bipolar depression) in youth ages 10 to 17.

Latuda is already approved as a monotherapy or adjunctive therapy with lithium or valproate for the treatment of adults with bipolar depression. The medication is also approved for the treatment of adults and adolescents (ages 13 to 17) with schizophrenia.

According to a press release by Sunovion Pharmaceuticals, which manufactures Latuda, the approval for the expanded indication of Latuda was based on data from a six-week, phase 3 clinical study of 347 children and adolescents with bipolar depression. After six weeks, the participants who received once-daily Latuda (20-80 mg/day) showed statistically significant improvements in depression symptoms compared with those taking placebo—as indicated by change from baseline on Children’s Depression Rating Scale, Revised (CDRS-R) total scores and Clinical Global Impression-Bipolar Version, Severity of Illness (CGI-BP-S) depression score.

The medication was generally well-tolerated, with nausea, weight gain, and insomnia being the most common treatment-related adverse effects.

“The FDA approval of this medicine for the treatment of pediatric patients with bipolar depression is significant for several reasons,” said Robert Findling, M.D., M.B.A., the director of child and adolescent psychiatry at the Johns Hopkins University School of Medicine in Sunovion’s press release. “First, it is a new treatment option for this vulnerable group of young people. Also, it is the first single-agent formulation to receive regulatory approval for this pediatric indication.”

To read more about this topic, see the Psychiatric News PsychoPharm article “Lurasidone May Work Better as Monotherapy in Older Patients With Bipolar Depression.”

Wednesday, March 7, 2018

Women With Schizophrenia May Be at Greater Risk of Breast Cancer, Meta-Analysis Finds

Women with schizophrenia may be at a 30% higher risk of breast cancer than women without schizophrenia, according to a meta-analysis published today in JAMA Psychiatry.

“Because breast cancer is the most common cancer in women, affecting 1 in 9 women during their lifetime, our findings highlight that intensive prevention and treatment against breast cancer are warranted for women with schizophrenia,” wrote study authors Chuanjun Zhuo, M.D., Ph.D., of Tianjin Medical University in China and Patrick Todd Triplett, M.D., of Johns Hopkins School of Medicine.

Zhuo and Triplett conducted a systematic search of PubMed and EMBASE databases; twelve cohort studies that included 125,760 women were included in the meta-analysis. The number of women with schizophrenia included in each study varied from 1,388 to 46,447, and the number of the breast cancer cases ranged from 42 to 1,042.

The meta-analysis revealed that schizophrenia was associated with a significantly increased risk of breast cancer incidence in women (standardized incidence ratio, 1.31); however, there were significant differences between the studies included in the meta-analysis.

“Future studies are needed to determine the association between schizophrenia and the different pathologic subtypes of breast cancer as well as whether the association may be affected by the woman’s age at breast cancer onset, antipsychotic medications used, and the cancer subtype,” Zhuo and Triplett wrote.

Despite the limitations of the meta-analysis, the authors noted the results indicate that women with schizophrenia deserve focused care for breast cancer screening and treatment.

“For the early prevention of breast cancer, an initial evaluation is needed to stratify the risk of breast cancer in women with schizophrenia. Subsequently, antipsychotics that may increase the prolactin level and produce a higher breast cancer risk should be avoided in high-risk women. Regular screening, including imaging or biomarker tests, should be performed. If an early diagnosis of breast cancer is made in women with schizophrenia, collaborations with oncologists are needed for clinical psychiatrists to make an optimal treatment recommendation,” they wrote.

For related information, see the Psychiatric News PsychoPharm article “Expert’s Corner: Best Practices for Treating Cancer Patients With Psychiatric Symptoms,” by Philip Bialer, M.D., of Memorial Sloan Kettering Cancer Center and the Psychiatric Services article “Mammography Among Women With Severe Mental Illness: Exploring Disparities Through a Large Retrospective Cohort Study.”

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Tuesday, March 6, 2018

Lithium, LAI Antipsychotics Found Best to Prevent Rehospitalization in Patients With Bipolar Disorder

Lithium appears to be the most effective medication for preventing rehospitalization for any reason among patients with bipolar disorder and should be the first-line of treatment, according to a report in JAMA Psychiatry. The study also revealed that long-acting injectable (LAI) antipsychotics were associated with substantially better outcomes compared with identical oral antipsychotics.

“When a patient with bipolar disorder uses an LAI, the patient’s risk of relapse leading to psychiatric hospitalization as well as all-cause hospitalization owing to mental or somatic illness is about 30% lower than during time periods when the same patient uses an identical oral antipsychotic,” Marrku Lähteenvuo, M.D., Ph.D., of the University of Eastern Finland and colleagues wrote. “Although more research is needed to support the notion, LAIs might offer a safe and effective option for relapse prevention in bipolar disorder for patients for whom lithium is not suitable."

Lähteenvuo and colleagues used Finnish national registry databases to examine the risk of psychiatric, cardiovascular, and all-cause hospitalization from January 1987 through December 2012 in patients in Finland who had been hospitalized for bipolar disorder. These databases include information on incidences, duration, and reasons for rehospitalization as well as information on reimbursed medications dispensed from pharmacies.

Among a cohort of more than 18,000 patients, 9,721 patients (54.0%) had at least one psychiatric rehospitalization during the study period. Of all medications studied, lithium was associated with the lowest risk of rehospitalization for any reason, with a hazard ratio (HR) of 0.71. Quetiapine fumarate, the most frequently used antipsychotic treatment, showed only modest effectiveness in reducing risk of all-cause rehospitalization (HR, 0.93).

Long-acting risperidone was associated with the lowest risk of psychiatric rehospitalization (HR, 0.58). The researchers also observed a marked association for reduced risk of psychiatric hospitalization with lithium (HR, 0.67).

“The main results of our study indicate that lithium is superior to other mood stabilizers and that LAIs are markedly better than identical oral formulations of antipsychotics.”

For related information see the Psychiatric News article, “Lithium Protects Against Suicide inBipolar Disorder, Study Finds.”


Monday, March 5, 2018

Tougher Gun Laws May Reduce Firearm Suicides, Homicides, Study Finds

Counties in and adjacent to states with stronger gun laws have fewer firearm deaths than counties in and adjacent to states with weaker laws, according to findings published today in JAMA Internal Medicine. The study suggests that strengthening state firearm policies may prevent firearm suicide and homicide, with benefits that may extend beyond state lines.

“States regulate how firearms are bought, sold, and tracked, as well as who may purchase them,” Elinore J. Kaufman, M.D., M.S.H.P., of the Department of Surgery at New York-Presbyterian Weill Cornell Medicine and colleagues wrote. “Stronger firearm policy environments have been associated with lower rates of firearm deaths, as have specific laws, such as licensing and inspection of firearm dealers, licensing and background checks for handgun sales, including private sales and laws regulating the availability of inexpensive handguns. Laws, however, vary widely among states, and evidence of their impact is limited.”

Kaufman and colleagues examined the effect of home state and out-of-state firearm laws on firearm death rates in U.S. counties between January 2010 and December 2014 by analyzing counts of death attributed to firearm suicide and homicide for 3,108 counties in the 48 contiguous states of the United States. Each county was assigned two scores, a state policy score based on the strength of its state firearm laws, and an interstate policy score based on the firearm laws of nearby states. Counties were divided into those with low, medium, and high home state and interstate policy scores.

The authors found that counties in states with high firearm policy scores had the lowest rates of firearm suicide and overall suicide, regardless of the strength of the firearm policies of other states. Counties with low state scores had the highest rates of firearm suicide. Stronger home state laws were also associated with lower rates of firearm homicide, while counties in states with weaker laws had lower rates of firearm homicide only when surrounding states had stronger laws.

“Because suicidal ideation is often transient, and because firearms are a highly lethal method of suicide, access to firearms is an important risk factor for completed suicide attempts,” the authors wrote. “Considered in the context of prior studies, our findings provide evidence that stronger state firearm laws could help to prevent firearm suicides, without an equivalent increase in suicide by other methods.”

“For homicides, the study provides evidence that when a state strengthens its firearm laws, both the state and its neighboring states may benefit,” added JAMA Internal Medicine Editor at Large Robert Steinbrook, M.D., in an accompanying editor’s note. “Because Congress has been unwilling or unable to act, the need for effective state firearm laws and policies in the United States has never been greater.”

For related information, see the Psychiatric News article “Firearms and Suicide: Risk Assessment and Management,” by Liza Gold, M.D.

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Friday, March 2, 2018

Early Psychosis Intervention Program Found to Increase Patient Contact With Psychiatrists, Reduce Mortality

People experiencing psychosis for the first time who used an early psychosis intervention (EPI) program in London, Ontario, had substantially lower rates of mortality in the two-year period after EPI program admission than those who did not use these services, according to a study published today in AJP in Advance

The findings add to growing evidence of the value of early psychosis intervention services to connect patients with care and improve health outcomes.

In the current study, Kelly K. Anderson, Ph.D., of the University of Western Ontario in Canada and colleagues examined the real-world effectiveness of a well-established EPI program over a 17-year period using linked health administrative data. They compared various health outcomes (such as rates of self-harm, suicide, and all-cause mortality) and use of health services (including primary care, outpatient psychiatry, and inpatient hospitalizations) by people who were using EPI services with a matched group of control subjects who were not accessing EPI services.

The authors found that in the first two years following admission, EPI service users were six times more likely to have had contact with a psychiatrist and had a more rapid time to the first psychiatric contact after program admission (an average of 13 days compared with 78 days for EPI nonusers). EPI service users were less likely to visit the emergency department compared with nonusers, but this group had higher rates of hospitalization.

There were no differences in rates of self-harm or deaths by suicide; however, EPI service users had a roughly 75% lower rate of all-cause mortality compared with nonusers. 

“[M]any of the observed benefits did not persist in the period from two to five years postadmission, when care is typically stepped down to medical management,” Anderson and colleagues wrote. “These changes in patterns of service use are likely a consequence of both reductions in the intensity of EPI services and improvements in the clinical status of nonusers, due to the natural trajectory of psychosis.”

They concluded, “Overall, our findings support the effectiveness of EPI services for the treatment of first-episode psychosis in the larger health care system context.”

To read more on this topic, see the Psychiatric News article “Psychosocial Treatments Found Effective for Early Psychosis.”

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Thursday, March 1, 2018

Peer Program Shows Promise in Detecting, Assisting High Schoolers With Depression

A peer depression program for high school students in Michigan increased their knowledge about depression, which could result in earlier detection of the condition and the negative impact it has on today’s youth, according to a study published today in Psychiatric Services in Advance.

About 7.5% of adolescents in the United States had depression in the past year, and it is associated with poorer academic performance, functional impairment, recurrent depression later in adulthood, substance use, and suicide. The Peer-to-Peer Depression Awareness Program (P2P) aims to decrease mental illness and promote well-being in schools by empowering high school students as both learners and educators, wrote Sagar V. Parikh, M.D., of the University of Michigan, Ann Arbor, and colleagues.

For the study, 121 students across 10 high schools organized into small teams (5 to 30 students/team) and were trained to develop and implement peer-to-peer depression awareness campaigns school-wide. Program goals include improving the school climate around mental health, directing students to resources, and encouraging help-seeking behavior. A total of 878 students, including those who participated directly in the creation and implementation of the P2P projects (P2P “team members”) and those who were not on the P2P teams, filled out questionnaires about depression before and after exposure to P2P.

At each school, about 71% of students who were not on the training and development teams said they were aware of the program’s general publicity campaign and 33% attended its additional specialized programs. Participants showed improved knowledge and attitudes toward depression, increased confidence in identifying and referring peers with depression, improved help-seeking intentions, and reduced stigma.

At the program’s conclusion, team members showed statistically significant improvements in confidence in identifying and helping others with depression and in comfort speaking with their peers about mental health issues. They also were more likely to believe other students would try to help a new student with depression. Other students at the school were more likely to ask for help if they had symptoms of depression for more than two weeks and were less embarrassed about being seen going to the school’s social worker or psychologist, the authors noted.

“Tapping into youth voices is a huge part of the success of the P2P program,” Parikh and colleagues wrote. Positive outcomes were observed among both student team members, as well as other students who were exposed to the campaigns’ messages, “demonstrating the program’s value as a universal prevention program,” they concluded.

For related information, see the Psychiatric News article “Rural Radio Program Becomes Mental Health Outreach to Youth.”

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Wednesday, February 28, 2018

Blaming Mass Shootings on Serious Mental Illness Has Harmful Effects, Says APA Past President

In the two weeks since a 19-year-old opened fire at Marjory Stoneman Douglas High School in Parkland, Fla., killing 17 students and faculty members, there has been much talk by politicians about the need to address untreated serious mental illness in the United States.

In an article published today in JAMA Psychiatry, APA Past President Renée Binder, M.D., and Matthew Hirschtritt, M.D., M.P.H., both of the University of California, San Francisco, wrote that while political rhetoric focusing the blame for mass shootings on individuals with serious mental illness may be “politically expedient,” such an approach “stigmatizes an already vulnerable and marginalized population, fails to identify individuals at the highest risk for committing violence with firearms, and distracts public attention from policy changes that are most likely to reduce the risk of gun violence.”

Binder and Hirschtritt summarized several studies that suggest serious mental illness is not a specific indicator for risk of violence. The article notes that such studies have found that people with mental illness are three times more likely to be victims than perpetrators of violence and only 4% of criminal violence in the United States can be attributed to people with mental illness.

Multiple factors other than serious mental illness contribute to violence risk, Binder and Hirschtritt wrote, including being male, young, having a history of perpetrating violence or being a victim of violence, and unlawful use of firearms. Certain triggers, including intoxication and severe stress, have also been shown to increase the risk of gun violence in people with and without mental illness.

“Addressing the risk of future mass shootings requires addressing a wide range of individual, community-level, and national and state policy factors, including decreasing access to guns, especially during periods of heightened violence risk,” they wrote. “Likewise, identifying and assisting those with serious mental illness requires the investment of resources and coordination of services, including supportive case managers, law enforcement and emergency personnel, and mental health clinicians.”

Psychiatrists should work to counter the perception that mental illness is the primary cause of gun violence, Binder told Psychiatric News. “I believe that psychiatrists have a role in advocacy and education. We have a responsibility in terms of educating people that guns are very dangerous, should be safely stored, and should be taken away from dangerous people,” she said. “Most people with mental illness will never commit a mass shooting, and this rhetoric leads to increased shame, societal reduction, stigmatization, and problems in gaining stable employment and housing.”

For related information, see the Psychiatric News AlertAPA Joins Other Physician Groups to Demand Action on Gun Violence.”

Tuesday, February 27, 2018

SSRIs Appear Superior to SSNRIs for Pediatric Anxiety, Study Shows

Selective serotonin reuptake inhibitors (SSRIs) appear to be superior to selective serotonin-norepinephrine reuptake inhibitors (SSNRIs) in the treatment of pediatric anxiety disorders, though both are associated with statistically significant improvement after two weeks, according to a meta-analysis in the Journal of the American Academy of Child and Adolescent Psychiatry

“These results are meaningful to clinicians as they choose which antidepressant class to use when treating anxious youth,” wrote Jeffrey Strawn, M.D., of the University of Cincinnati College of Medicine and colleagues. “Additionally, given the magnitude and trajectory of SSRI response, relative to SSNRI response observed herein, clinicians might preferentially use SSRIs as first-line psychopharmacologic interventions in pediatric patients with anxiety disorders.” 

Strawn and colleagues searched the literature for prospective, randomized, placebo-controlled trials (RCTs) that evaluated the efficacy of SSRIs or SSNRIs in the treatment of social, generalized, and/or separation anxiety disorder in children or adolescents. Overall, nine double-blind RCTs (1,805 patients) conducted between 1997 and 2014 were included in the analysis. 

Four SSRIs were evaluated: fluoxetine, fluvoxamine, paroxetine, and sertraline. Three SSNRIs were evaluated: atomoxetine, venlafaxine, and duloxetine. Five studies were federally funded, and four were funded by industry. All studies were conducted in outpatient settings. The primary outcome for these analyses was the change in Pediatric Anxiety Rating Scale (PARS) total score from baseline to endpoint.

Patients taking both SSRIs and SSNRIs improved significantly by week two over those taking placebo and continued to have statistically significant improvement throughout the study period. However, treatment response among those taking SSRIs was statistically greater at week two than among those taking SSNRIs, and that difference remained statistically significant over the subsequent 10 weeks of treatment. 

“Our results suggest that antidepressant response in pediatric patients occurs early in the course of treatment and occurs with a greater magnitude and more rapid trajectory with SSRIs compared to SSNRIs,” Strawn and colleagues wrote. “These data raise the possibility that SSRIs should be first-line antidepressants in youth with anxiety disorders and extend prior observations in pediatric patients with anxiety that more serotonergically selective agents may be more effective.”

For related information, see the Psychiatric News article “SSRIs/SNRIs Effective in Children, but Risks, Benefits Vary.” 

(Image: Phovoir/Shutterstock)

Monday, February 26, 2018

Patients Taking SSRIs/SNRIs in Combination With Triptans at Low Risk of Serotonin Syndrome, Study Finds

In 2006, the Food and Drug Administration (FDA) issued a health advisory warning that patients who take selective serotonin reuptake inhibitors or selective norepinephrine reuptake inhibitors (SSRIs/SNRIs) together with triptan antimigraine drugs may be at a heightened risk of serotonin syndrome—a potentially fatal condition believed to arise from elevated serotonin levels. This advisory was based in part on several case reports of serotonin syndrome in patients treated with triptans and SSRIs/SNRIs.

A study published today in JAMA Neurology suggests that the risk of serotonin syndrome associated with concomitant use of triptans and SSRIs/SNRIs is low.

“In [a] large population-based study with more than 30,000 person-years of exposure to coprescription of these drugs, we found no cases of life threatening serotonin syndrome and no cases in which triptan use was unequivocally implicated as a cause,” Yulia Orlova, M.D., Ph.D., of the University of Florida College of Medicine and colleagues wrote. “Our results cast doubt on the validity of the FDA advisory and suggest that it should be reconsidered.”

The authors assessed data from the Partners Research Patient Data Registry, which contains health record information for more than 6 million members of the Partners HealthCare Network in the greater Boston area. They identified 19,017 patients who had received a prescription for both a triptan and SSRI/SNRI at some point between January 1, 2001, and December 31, 2014.

In this group, serotonin syndrome had been clinically suspected in 17 patients, though only in seven cases did the syndrome occur in the same year that a patient had a documented prescription of both medications (resulting in an incidence rate of 2.3 cases per 10,000 person-years of medication exposure). Of these seven patients, only two were classified with definite serotonin syndrome (resulting in an incidence rate of 0.6 cases per 10,000 person-years of medication exposure).

“Overall, our results are reassuring and suggest that patients with coexisting affective disorders and migraine need not forgo management of one condition to treat the other,” the authors concluded.

For related information, see the Psychiatric News PsychoPharm article “Common Pain Relievers Do Not Appear to Interfere With Mood Stabilizers.”

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Friday, February 23, 2018

Varenicline May Lower Heavy Drinking, Smoking in Men With AUD

Varenicline, an FDA-approved smoking-cessation medication (Chantix), may be effective in treating both alcohol use disorder (AUD) and smoking in men, according to a study in the February issue of JAMA Psychiatry.

“Men appeared to derive benefit from varenicline, compared with placebo, on measures of heavy drinking, whereas women did better taking placebo,” wrote lead author Stephanie S. O’Malley, Ph.D., director of the Division of Substance Abuse Research in Psychiatry at Yale School of Medicine.

Researchers conducted the phase 2, randomized, double-blind, placebo-controlled trial at two outpatient clinics (New York City and New Haven, Conn.) from September 19, 2012, to August 31, 2015. The researchers recruited men and women aged 18 to 70 who were seeking treatment for AUD. Individuals who met the criteria for alcohol dependence (according to the DSM-IV-TR), reported heavy drinking (≥5 standard alcoholic drinks for men and ≥4 drinks for women) two or more times a week and cigarette smoking two or more times per week were included in the trial.

O’Malley and colleagues randomly assigned 131 participants to receive either 2 mg of varenicline or placebo daily for 16 weeks. Medication was titrated in the following standard doses: 0.5 mg once daily for three days, 0.5 mg twice daily for four days, and 1 mg twice daily for the remainder of the 16-week treatment. Daily medication adherence was monitored through a combination of pill counts returned from blister packs and self-reported compliance.

Over the course of the trial, participants attended 12 medical management sessions during which they met with a medical professional to discuss the tolerability of the assigned medication, medication adherence, and the importance of drinking goals as well as the development and implementation of strategies for changing drinking behaviors. The participants were also asked about their drinking and smoking behavior, adverse effects of the medication, changes in mood, and more.

The mean change from baseline in the percentage of heavy drinking days in the overall sample by the end of the study was not different between the placebo and medication groups, but varenicline appeared to have different effects on drinking in men and women. Compared with placebo, varenicline resulted in a greater decrease in percentage of heavy drinking days in men and a smaller decrease in percentage of heavy drinking days in women. Even though the subjects were not seeking or provided smoking-cessation counseling, varenicline resulted in significantly higher rates of smoking abstinence compared with placebo (13% vs 0%) at the end of treatment.

“This study adds to the growing body of evidence suggesting varenicline to be well tolerated in those with active substance use disorders,” wrote A. Eden Evans, M.D., Ph.D., and John F. Kelly, Ph.D., both of the Center for Addiction Medicine at Massachusetts General Hospital and Harvard Medical School., in an accompanying editorial in JAMA Psychiatry. “These findings highlight the importance of the National Institutes of Health’s emphasis on systematically evaluating sex or gender in treatment effects and add to the converging evidence of the need for more specific and targeted treatments for women and men.”

For related information, see the Psychiatric News article “APA Releases Practice Guideline for AUD Pharmacotherapy.”

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Thursday, February 22, 2018

Only 35% of Parents With Child At Risk of Self-Harm Properly Store Firearms, Survey Finds

A child’s history of risk factors for self-harm does not appear to influence caretaker decisions about whether to keep firearms in the home, or whether those firearms are kept unloaded and in locked storage.

That’s the finding from an analysis of data from an online survey published in Pediatrics.

“Given the prevalence of household firearms in the United States, our findings suggest that millions of U.S. children are placed at substantially higher risk of fatal firearm injury, especially suicide, than would be the case were parents to follow guidelines first put forward by the AAP [American Academy of Pediatrics] more than a quarter century ago,” wrote John Scott, B.S., Deborah Azrael, Ph.D., and Matthew Miller, M.D., M.Sc., of Northeastern University and Harvard University.

The researchers used data from a Web-based survey conducted by the survey firm Growth for Knowledge (GfK) to assess firearm ownership, storage practices, and use among a nationally representative sample of U.S. adults. Respondents were asked about gun ownership and about various storage practices for their household guns, including the number of guns stored and whether they were locked and unloaded. Participants were also asked if there were children living in the household and if so, what their relationship was to these children.

Respondents who reported to be the caregiver or health care decision-maker (“parent”) of a child under 18, were also asked if this child had attention-deficit/hyperactivity disorder (ADHD), depression, or mental health conditions other than depression. Respondents who answered “yes” to any of these were said to have a child with a self-harm risk factor. (Respondents were not asked whether children ever received a formal diagnosis.)

Of 3,949 respondents, approximately 1 in 3 U.S. households contained firearms (34.8%), irrespective of whether the household included children. Among the subset of adults who self-identified as parents, approximately 2 in 5 households contained firearms (42.4%).

Among parents who own guns, 34.9% stored all guns locked and unloaded when they had a child with a history of self-harm risk factors, compared with 31.8% when none of their children had such a history.

In an accompanying editorial, David C. Grossman, M.D., M.P.H., of the Kaiser Permanente Washington Health Research Institute, said clinicians caring for teenagers play a critical role in preventing youth suicide, including routine screening of adolescents for depression and ascertaining information about firearms in the household and their storage.

“When screening yields concerns of depression, a natural opportunity arises to ask about access to household firearms and provide intensive behavioral counseling on safe storage,” Grossman wrote. “Ongoing treatment of teenage depression involves systematic monitoring of treatment effectiveness, possibly including message reinforcement about firearm storage. Clinicians may need to engage other family members to ensure that treatment and storage recommendations are followed.”

For related information, see the Psychiatric News article “Firearms and Suicide: Risk Assessment and Management,” by Liza Gold, M.D.

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Wednesday, February 21, 2018

Depression Screening, Treatment Can Improve Outcomes of Individuals With HIV

The more days that an adult living with HIV spends depressed, the greater the risk he or she will miss appointments for HIV primary care, experience HIV treatment failure, and/or die prematurely, according to a study published today in JAMA Psychiatry.

“Even modest increases in time spent depressed led to clinically meaningful upticks in negative outcomes,” lead author Brian Pence, Ph.D., of the University of North Carolina at Chapel Hill, told Psychiatric News by email. “The implication [of these findings] is that regular depression screening and rapid, evidence-based depression treatment—by shortening the duration of depression—hold the potential to have a meaningful impact on HIV outcomes,” he said.

To examine the association between the persistence of depression and multiple HIV care continuum indicators, Pence and colleagues analyzed data on adult patients who received HIV care at six U.S. academic medical centers participating in the Center for AIDS Research Network of Integrated Clinical Systems (CNICS) between September 22, 2005, and August 6, 2015. As part of routine clinical visits, patients were regularly given the PHQ-9 every six or so months.

Pence and colleagues focused their analysis on information collected on CNICS participants with two or more consecutive PHQ-9 measures (defined as two PHQ-9 measures separated by less than 365 days). Patients entered and remained in the analysis until one of the following occurred: death, a lapse in PHQ-9 measures (12 months after the last consecutive PHQ-9 measure), loss to care (≥12 months without an HIV primary care appointment), six years’ follow-up, or until the end of the available data from the patient’s site. The main outcomes assessed during the follow-up period included missed HIV primary care appointments, detectable HIV viral load (HIV RNA viral load measure of 75 copies/mL or more), and all-cause mortality.

A total of 5,927 participants were included in the analysis. During the follow-up period, Pence and colleagues found that the participants’ median percentage of days with depression was 14%, 10,361 of 55,040 scheduled visits (18.8) were missed, 6,191 of 28,455 viral loads (21.8%) were detectable, and the mortality rate was 1.5 deaths per 100 person-years.

“Increasing PDD [percentage of days with depression] was associated in a dose-response fashion with an increased risk of missed appointments, increased risk of detectable viral load, and accelerated mortality. Each 25% increase in PDD led to an 8% increase in the risk that a particular scheduled appointment would be missed, a 5% increase in the risk that a particular viral load would be detectable, and a 19% increase in the mortality hazard,” the authors wrote.

For related information, see the Psychiatric News article “Advisory Council Member Offers Voice for Psychiatry in New HIV/AIDS Strategy.”

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Tuesday, February 20, 2018

Adolescents With Depression Found to Benefit From Collaborative Care Program

Depression is common among adolescents, yet an estimated 40% never receive treatment. A study in Psychiatric Services in Advance suggests that embedding psychiatric services within a primary care setting can reduce depressive symptoms in this group.

For the study, Nathan Shippee, Ph.D., of the University of Minnesota, Minneapolis, and colleagues from the Mayo Clinic assessed the effectiveness of EMERALD (Early Management and Evidence-based Recognition of Adolescents Living with Depression), a collaborative care program in a busy primary care practice in the Midwest.

Patients aged 12 to 18 with a depression diagnosis score of ≥10 on the nine-item Patient Health Questionnaire for Adolescents (PHQ-9A) who did not have a bipolar disorder diagnosis were eligible to participate. The sample included 162 EMERALD participants and 499 non-EMERALD participants with the same diagnostic profile.

After receiving an initial diagnosis of depression from a primary care provider (PCP), patients and parents who verbally agreed to participate in the EMERALD program were referred to a registered nurse care coordinator trained in depression management and motivational interviewing. For each adolescent, the nurse checked in by phone or face-to-face weekly or biweekly, and with one or both parents biweekly. The nurse used motivational interviewing and other strategies to encourage patients to identify specific concerns and goals for each visit. In weekly case review meetings with the nurse, a child and adolescent psychiatrist made treatment recommendations. The nurse passed the recommendations to the PCP, who made the final decision. The nurse then worked with the patient and his or her parents on the recommendations.

Patients who did not enter EMERALD received usual care from a PCP.

Patient outcomes were tracked via a clinical registry. The primary clinical outcomes were six-month remission of depression (score <5) and six-month treatment response (>50% reduction from baseline), as measured by the PHQ-9A. Overall, patients receiving collaborative mental health care experienced higher rates of remission (11 percentage points higher) and treatment response (14 percentage points higher) than patients who received treatment as usual.

“Practices may want to consider implementation of an analogous model of care to improve depression outcomes among adolescents,” the authors wrote. “Future studies could examine which groups might benefit most and flexible payment models to support these services.”

For related information, see the Psychiatric News article “Collaborative Care for Youth: Statewide Success Stories,” by Robert J. Hilt, M.D., M.S.

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Friday, February 16, 2018

APA Joins Other Physician Groups to Demand Action on Gun Violence

In the aftermath of Wednesday’s shooting that killed 17 students and staff members at Marjory Stoneman Douglas High School in Parkland, Fla., APA and four organizations representing 450,000 physicians and medical students called on President Donald Trump and Congress to take meaningful action against gun violence.

Joining with APA were the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the American College of Physicians.

“Gun violence is a public health epidemic that is growing in frequency and lethality, and it is taking a toll on our patients,” the groups said in a statement released today. “We urge our national leaders to recognize in this moment what the medical community has long understood: we must treat this epidemic no differently than we would any other pervasive threat to public health. We must identify the causes and take evidence-based approaches to prevent future suffering.”

The groups have asked the president and Congress to take the following actions:
  • Label violence caused by the use of guns a national public health epidemic.
  • Fund appropriate research at the Centers for Disease Control and Prevention as part of the FY 2018 omnibus spending package.
  • Establish constitutionally appropriate restrictions on the manufacture and sale, for civilian use, of large-capacity magazines and firearms with features designed to increase their rapid and extended killing capacity.
While mass shootings attract much attention from the public and the media, the groups noted that current policies regarding access to guns in this country expose Americans daily to the risks of violent acts including suicide, homicide, and unintentional injury.

“The families of the victims in Parkland and all those whose lives have been impacted by daily acts of gun violence deserve more than our thoughts and prayers. They need action from the highest levels of our government to stop this epidemic of gun violence now,” the statement concluded.

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Thursday, February 15, 2018

FDA Approves First Blood Test to Detect Concussions

The Food and Drug Administration (FDA) on Wednesday approved the first blood test to evaluate mild TBI (mTBI) or concussion.

The test, called the Brain Trauma Indicator, works by measuring levels of two proteinsUCH-L1 (ubiquitin C-terminal hydrolase L1) and GFAP (glial fibrillary acidic protein). These proteins are released from the brain following a head injury and appear in the blood within hours of the injury.

“A blood-testing option for the evaluation of mTBI/concussion not only provides health care professionals with a new tool, but also sets the stage for a more modernized standard of care for testing of suspected cases,” FDA Commissioner Scott Gottlieb, M.D., said in a press release.

Health care professionals currently evaluate patients suspected of head injuries with the 15-point Glascow Coma Scale followed by a computed tomography (CT) scan of the head to detect intracranial lesions that may need follow-up care. More than 90% of patients presenting to the emergency department with mild TBI or concussion have a negative CT scan, according to Banyan Biomarkers, Inc., the developer of the Brain Trauma Indicator.

The FDA evaluated data from a multicenter, prospective clinical study of 1,947 individual blood samples from adults with suspected mTBI/concussion and reviewed the product’s performance by comparing mTBI/concussion blood tests results with CT scan results. According to the FDA, the Brain Trauma Indicator was able to predict the presence of intracranial lesions on a CT scan 97.5% of the time and those who did not have intracranial lesions on a CT scan 99.6% of the time.

“These findings indicate that the test can reliably predict the absence of intracranial lesions and that health care professionals can incorporate this tool into the standard of care for patients to rule out the need for a CT scan in at least one-third of patients who are suspected of having mTBI,” the agency noted in the press release. The results of the test are available within three to four hours.

For related information, see the Psychiatric News article “Blood Test May Detect Concussions Days Later.”


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